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          <h1 class="post-title" itemprop="name headline">《Newman and Carranza's Clinical Periodontology》读书笔记10</h1>
        

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        <p>第50章 续3<br>龈下刮治和根面平整技术<br>龈下牙石通常比龈上牙石要硬，常嵌入缺陷中去，使得去除牙石更加困难。覆盖软组织会给龈下器械操作带来困难，视线会被出血阻挡。牙医必须很大程度上依赖于触觉感受来探测牙石和缺陷，引导器械刮除牙石和平整根面，并评估效果。<br>因为看不见，牙医必须有牙体表面的完整图像的印象，以预测可能遇到的变异，并持续的根据触觉感受确认或者修改心中的图像，如器械的位置等。正是这些复杂性和精确性对视觉，意识和操作技能上的要求使得龈下刮治成为所有牙科技术中最困难的一个（应该是之一吧？）。刮治器的弧形的刃，圆形的尖端，以及弧形的背部，使得它可以被插入袋的基底部，适应于各种不同的牙齿结构，并使组织移位和创伤降到最小。<br>其它一些器械也可以使用。尽管薄的专为深袋和根分叉区域刮治设计的超声工作尖可以更容易的插入龈下，它们必须在低功率条件下使用。当低功率刮治用在厚的牙结石或者坚韧的板状牙石上时，薄的超声工作尖更倾向于抛光牙石，而不是整块的移除它。因此超声龈下刮治应该在仔细的用探针评估后使用，另外完成后还要使用手用刮治器械刮治。<br>可以使用通用刮治器或者区域专用的Gracey刮治器。刮治器用改良握笔式方法握持，建立稳定的支点。用正确的切割边缘龋轻轻的匹配牙齿，使低柄(lower shank)与牙体表面保持平行。短柄顺着牙齿移动，刃的正面就可以靠近牙齿表面切割。接着刃插入牙龈，用轻探诊的力到达袋底。当切割边缘到达袋底时，建立一个45°-90°的工作角度（回忆：低于45°，将牙石抛光，大于90°，越过牙石），相对牙体表面侧向用力。牙石通过一系列有控制的、重叠的，短的，有力地施力来去除，主要使用的是腕臂的运动。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0069-lcyzbxbj10/01.jpg"><br>当牙石移除以后，切割端的阻力消失，只有轻微的粗糙感还存在。使用长的，轻微的力进行根面平整，对牙体的侧向力也要减轻，直到牙根表面彻底光滑和坚硬。器械柄必须在拇指和其它手指之间小心的翻转以保持工作刃与牙体表面贴合，尤其在遇到一些线角，发育沟裂，和牙体的其它形态改变时。刮治和根面平整应该局限于有牙石或牙骨质改变的牙体部分，这些区域被称为器械工作区(instrumentation zone)。清洁器械，定期研磨，因为钝的器械，会导致控制丧失。<br>在牙体表面施加的侧向力的大小取决于牙石的性质和是在做刮治还是根面平整。如果牙石刮除后还用大的侧向力，并且短促的，不断改变方向的用力，会导致根面出现沟槽和凹陷，引起粗糙。如果是长的，甚至是暴力，可能导致过度去除牙根结构，造成一个光滑的但是“有沟痕”(ditched or riffled)的牙根表面。为了避免这种情况，一旦牙石去除，就应该将用力由短的，有力地刮治转变为长的，轻柔的根面平整。<br>当用刮治力刮除牙石时，可以将最大的侧向力集中于刃的低1/3端。这部分末端位于牙石的根方区，用短的垂直向或倾斜向力使牙石从牙体表面分离。不要将刃完全撤出牙周袋，而是将尖端重新定位于剩余牙石的底部位置。再用同样的垂直或倾斜力，与上一次刮除的区域部分重叠（叠瓦状）。重复这个步骤，直到整块牙石被刮除干净。这种叠瓦状操作，确保整个器械工作区域被完全覆盖。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0069-lcyzbxbj10/02.jpg"><br>不建议整体刮除一大块坚硬的牙石，或者长度超过工作刃边缘的牙石，因为那样力会分散到整个工作刃边缘而不是集中于一点。这样就需要更大的力量。这样一方面会影响触觉感觉，另一方面也容易导致失去控制而造成组织损伤。一个单独的重的力通常并不足以移除整块牙石。常常是刃跳过牙石表面。随后用力刮除常常导致一层一层的刮除牙石。这样牙石常常被磨成薄的，光滑的片状，这样就更难将其从牙根表面清除。<br>一个常犯的错误是器械难以到达邻接区的根方的区域。这些区域是相对难以到达的区域，需要更多的技能。至少要将器械从颊舌侧伸入到达接触区超过一半的位置，以保证没有残留牙石和粗糙区域。对于设计良好的器械，可以通过使短柄与牙体长轴保持平行来达到。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0069-lcyzbxbj10/03.jpg"><br>(这张图就更清楚了，刮治器要怎么放）<br>如果短柄与牙体呈一定角度，或者倾斜离开牙体，短柄会碰到牙体或者解除区域，阻挡器械进入邻接区用力。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0069-lcyzbxbj10/04.jpg"><br>手指支点与工作区域的关系很重要：①支点必须允许器械的短柄与牙体表面平行或接近平行。这是获得理想的工作角度所必须的。②支点的放置需要使操作者能够运用腕臂的力量。在上颌后牙的某些区域，要达到这个要求就必须使用口外或对颌的支点。当使用口内支点时，支点要尽可能靠近工作区域，以满足这两个要求。如果支点过远，术者的中指和其它四个手指将被迫分开以保持器械平行和适当工作角度的要求。有效的腕臂用力只有在这两个手指保持在一起的时候才能达到。<br>随着器械从一个牙位到下一个牙位，体位和支点的位置必须经常调整或改变，以满足平行性和腕臂运动的要求。不同牙位的具体要求如下，每个区域都有多种方法，这些方法都是可能和可以接受的，只要它们能提供相同的效果和舒适度。<br>①右侧上颌颊侧（第一象限颊侧）<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0069-lcyzbxbj10/05.jpg"><br>体位：侧位（side）<br>照明：直射<br>视觉：直视（对于磨牙远中面可以间接观察）<br>牵拉：用口镜或非操作手的示指。<br>支点：口外，手掌向上（palm up）。中指或无名指的后背放置于右侧下颌骨的外侧。<br>②右侧上颌后牙区域，前磨牙区，颊侧。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0069-lcyzbxbj10/06.jpg"><br>体位：侧位或后位。<br>照明：直射<br>视觉：直视<br>牵拉：用口镜或非操作手的示指。<br>支点：口内，手掌向上。无名指放置于上颌邻近后牙的咬合面上。<br>③右侧上颌后牙腭侧<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0069-lcyzbxbj10/07.jpg"><br>体位：侧位或前位<br>照明：直接或间接。<br>视觉：直接或间接。<br>牵拉：不用<br>支点：口外，手掌向上。中指和无名指后背放置于右侧下颌骨侧方。<br>④右侧上颌后牙腭侧（应该是指前磨牙区）<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0069-lcyzbxbj10/08.jpg"><br>体位：正位<br>照明：直接<br>视觉：直接<br>牵拉：无<br>支点：口内，手掌向上。放在手指上。非操作手的示指放于右上后牙颌面上，操作手的无名指或示指放于其上。<br>⑤上颌前牙区，唇侧，远离术者的表面（surfaces away from the operator)<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0069-lcyzbxbj10/09.jpg"><br>体位：后位<br>照明：直接<br>视觉：直接<br>牵拉：非操作手的示指<br>支点：口内，手掌向上。无名指放于上颌切牙的切缘或后牙的颌面。<br>⑥上颌切牙唇侧，靠近术者的表面<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0069-lcyzbxbj10/10.jpg"><br>体位：前位<br>照明：直接<br>视觉：直接<br>牵拉：非操作手的示指<br>支点：口内支点，手掌向下。无名指放于上颌邻牙的切缘或者咬合面。<br>⑦上颌前牙腭侧，靠近术者的牙面（away from如果在患者右边，指左边的牙面吧。)<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0069-lcyzbxbj10/11.jpg"><br>体位：后位<br>照明：间接<br>视觉：间接<br>牵拉：不用<br>支点：口内，手掌向上。无名指放于上颌邻牙的切缘或者咬合面。<br>⑧左侧上颌后牙颊侧（前磨牙）<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0069-lcyzbxbj10/12.jpg"><br>体位：侧位或后位<br>照明：间接或直接<br>视觉：间接或直接<br>牵拉：口镜<br>支点：口外，手掌向下。中指和无名指的指腹放置于左侧下颌骨的外侧面。<br>⑨下颌后牙颊侧（磨牙区）<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0069-lcyzbxbj10/13.jpg"><br>体位：后位或侧位<br>照明：直接或间接<br>视觉：直接或间接<br>牵拉：口镜<br>支点：口内，手掌向上。无名指放置于左侧上颌牙切缘或咬合面上。<br>⑩左侧上颌后牙腭侧<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0069-lcyzbxbj10/14.jpg"><br>体位：前位<br>照明：直接<br>视觉：直接<br>牵拉：不用<br>支点：口内，手掌向下。对颌牙弓，加强型。无名指在下颌切牙切缘或下颌前磨牙颊侧表面放置，用非操作手的示指加强。<br>⑪左侧上颌后牙腭侧<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0069-lcyzbxbj10/15.jpg"><br>体位：前位<br>照明：直接或间接<br>视觉：直接或间接<br>牵拉：不用<br>支点：口外，手掌向下。中指和无名指指腹放置于左侧下颌骨侧面。非操作手持口镜进行间接照明。<br>⑫左侧上颌后牙腭侧<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0069-lcyzbxbj10/16.jpg"><br>体位：侧位或前位<br>照明：直接<br>视觉：直接<br>牵拉：不用<br>支点：口内，手掌向上。无名指放于上颌邻近牙齿的咬合面上。<br>⑬左侧下颌后牙颊侧<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0069-lcyzbxbj10/17.jpg"><br>体位：侧位或后位<br>照明：直接<br>视觉：直接或间接<br>牵拉：非操作手的示指或口镜牵拉<br>支点：口内，手掌向下。无名指放置于下颌邻近牙齿的切缘或咬合面。<br>⑭左侧下颌后牙舌侧<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0069-lcyzbxbj10/18.jpg"><br>体位：前位或侧位<br>照明：直接或间接<br>视觉：直接<br>牵拉：口镜挡住舌<br>支点：口内，手掌向下。无名指放置于下颌邻近牙齿的切缘或咬合面。<br>⑮下颌前牙唇侧，靠近术者的牙面<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0069-lcyzbxbj10/19.jpg"><br>体位：前位<br>照明：直接<br>视觉：直接<br>牵拉：非操作手的示指。<br>支点：口内，手掌向下。无名指放置于下颌邻近牙齿的切缘或咬合面。<br>⑯下颌前牙唇侧，远离术者。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0069-lcyzbxbj10/20.jpg"><br>体位：后位<br>照明：直接<br>视觉：直接<br>牵拉：非操作手的示指或拇指<br>支点：口内，手掌向下。无名指放置于下颌邻近牙齿的切缘或咬合面。<br>⑰下颌前牙舌侧，远离术者的牙面<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0069-lcyzbxbj10/21.jpg"><br>体位：后位<br>照明：直接或间接<br>视觉：直接或间接<br>牵拉：口镜挡住舌<br>支点：口内，手掌向下。无名指放置于下颌邻近牙齿的切缘或咬合面。<br>⑱下颌右侧后牙，颊面<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0069-lcyzbxbj10/22.jpg"><br>体位：侧位或前位<br>照明：直接<br>视觉：直接<br>牵拉：口镜或非操作手的示指。<br>支点：口内，手掌向下。无名指放置于下颌邻近牙齿的切缘或咬合面。<br>⑲右侧下颌后牙舌侧<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0069-lcyzbxbj10/23.jpg"><br>体位：前位<br>照明：直接或间接<br>视觉：直接或间接<br>牵拉：口镜挡住舌<br>支点：口内，手掌向下。无名指放置于下颌邻近牙齿的切缘或咬合面。<br>（全部背下来没必要，只要遵循原则就行了，第一保证器械短柄与牙体平行，第二方便腕臂施力。做得多了自然就形成动作记忆了。）<br>这部分讲具体的手工刮治技术了，就是一些细节：方向，角度，力度，层叠刮除等。<br>下面是超声洁刮治了。</p>
<p>我发文章的三个地方，欢迎大家在朋友圈等地方分享，欢迎点“在看”。<br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的知乎文章地址： <a target="_blank" rel="noopener" href="https://www.zhihu.com/people/zhao-you-min/posts">https://www.zhihu.com/people/zhao-you-min/posts</a><br>我的微信个人订阅号：赵瑜敏的口腔医学学习园地</p>
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